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Self-Study Modules on Tuberculosis

Module 7: Confidentiality in Tuberculosis Control
Answers To Case Studies

7.1 Van is a cook at a local restaurant. He came to the health
department after his girlfriend, Tanya, told him that she had been
diagnosed with TB disease. After undergoing tests for TB, it was
confirmed that Van also has TB disease. Van is not from the United
States and does not have the proper documents to be working in this
country. During the contact investigation interview, Van was reluctant
to provide information on where he worked. He did not want to get
his employer in trouble and he does not want to be reported to immigration
authorities. Van was also afraid that if people at work found out
that he had TB that he would lose his job. Finally, Van also admitted
to injecting drugs with some friends once in awhile, but was reluctant
to give their names because he didn't want his friends to know that
he had TB. He was also afraid his friends might be reported to the
police.

Why is it important to protect Van's confidentiality?

By bringing his health problem to the attention of a health
care worker, Van has entrusted personal information to the health
care worker. If sensitive personal information about Van is
revealed to a coworker, friend, or acquaintance without Van's
permission, there may be serious consequences.

His relationship with the health care worker may be
damaged, possibly affecting his care

He may lose his job or be evicted from housing

He may be stigmatized or rejected by his friends, family,
and others

The health care worker may lose the trust of other patients

What can the health care worker do to develop trust
with Van?

There are three ways to earn a patient's trust including

Respecting Van's autonomy, his right to determine what
will be done with his body, belongings, and personal information

Freely providing complete and accurate information to
him

Rigorously maintaining confidentiality

Van has a lot of fear that others (employer, friends) will
find out about his TB disease. He is also afraid he will be
reported to immigration authorities. Van should be reassured
that the information he shares, as well as information regarding
his diagnosis, will not be shared with others and that the health
care worker will keep all information confidential.

7.2 Mr. Alvin Jones is a patient with infectious TB disease
who has been recently discharged from the hospital. While hospitalized,
Mr. Jones was very sick and had no problems with taking his medication
or undergoing diagnostic procedures. Now that he is back at home,
he has stopped taking his medications, has missed two clinic appointments,
and has continually refused to speak to the health care worker assigned
to his case. After many attempts to inform Mr. Jones of his condition
and the need for treatment, the health department finally obtained
a court order requiring Mr. Jones to complete a directly observed
therapy regimen. Mr. Jones, not wanting to get into legal problems,
has reluctantly agreed to meet with the health care worker to establish
a treatment plan.

Why is the health department able to obtain a court
order, despite Mr. Jones' wish to stop treatment?

Sometimes the right to autonomy can be overridden in the
interest of protecting others who may be harmed by the patient's
decisions. This can happen in TB control when a patient with
infectious or potentially infectious TB disease refuses treatment.
Because Mr. Jones poses a significant health threat to other
people, he can be ordered by a court to participate in and complete
his DOT. If he does not comply with this order, he could be
detained until treatment is completed, depending on the strength
of state and local TB control laws in his jurisdiction.

What should be done to protect Mr. Jones' rights
to autonomy, information, and privacy?

Autonomy is the right of a patient to determine what will
be done with his or her body, personal belongings, and personal
information. Although Mr. Jones has been ordered to comply with
treatment, he should be able to participate in decisions about
how his treatment is carried out. Health department staff should
discuss the treatment and adherence plans with Mr. Jones, allowing
him to have some input into these plans whenever feasible.

Mr. Jones has a right to information about his medical diagnosis,
treatment regimen, and progress, as well as a right to review
the information in his medical records. The health care worker
should be careful to follow due process in working with Mr.
Jones and documenting his therapy.

In this situation, maintaining the confidentiality of Mr.
Jones' information is critical. Although disclosure was necessary
to obtain the court order, it should have been strictly limited
to those public health authorities who needed the information.
Any health department or law enforcement officials who are involved
in enforcing Mr. Jones' order should take great care to protect
his right to privacy. A breach of confidentiality in these circumstances
can further undermine the patient-health care worker relationship
and lead to continued resistance to adherence-promoting measures.

7.3. Ms. Rita Ramirez, a young mother of two children, has been
diagnosed with infectious TB. She is also infected with HIV, which
she contracted through sexual contact with her current partner,
an HIV-infected injection drug user. Ms. Ramirez works in a factory
that assembles small parts for electronic appliances; there are
over 250 workers at the plant. She is very concerned about her job
security, having only recently begun work on a temporary basis.
Ms. Ramirez has consented to a treatment plan including a DOT regimen
and is willing to cooperate with the contact investigation. She
will inform her household contacts, but does not want anyone at
work to know she has TB disease.

Why is it important to protect the confidentiality
of Ms. Ramirez' information?

By bringing her health problem to the attention of a health
care worker, Ms. Ramirez has entrusted personal information
to the health care worker. Both TB disease and HIV infection
have some social stigma attached to them and have serious implications
for the patient's health. If sensitive personal information
is revealed to a coworker, friend, or acquaintance without Ms.
Ramirez permission, there may be serious consequences:

Her relationship with the health care worker may be
damaged, possibly affecting her care

She may lose her job or be evicted from housing

She may be stigmatized or rejected by her family, friends,
or others

The health care worker may lose the trust of other patients

What steps should be taken to ensure that confidentiality
is maintained?

Ms. Ramirez should be told about her right to privacy and
the measures that will be taken to maintain confidentiality.
The health care worker in this case should be sensitive to her
fears, explain the importance of screening the contacts, and
assure her that all information, including her name, will be
kept confidential and will not be shared with authorities. Health
department staff will have to inform the workers of their possible
exposure and screen people in the workplace. This should be
done with as much discretion as possible, usually after some
negotiation with the employer about the best way of informing
workers, offering screening (on-site if possible), and providing
follow-up care. It should also be pointed out to the patient
that the health department has no control over family members,
friends, and others whom she informs of her diagnosis and their
exposure; she should make sure these are people she trusts and
should stress the need for them to be discreet with her personal
information.

Because Ms. Ramirez is infected with HIV, the health care
worker should explain who is considered a contact for the purpose
of TB investigations and that both Ms. Ramirez's name and her
HIV status will be kept confidential. HIV reports are held in
strictest confidence and in many jurisdictions are protected
by statute from subpoena. For clinical care purposes, however,
HIV-related information should be shared between TB care providers
and other health care providers in accordance with state and
local laws.

7.4 Rolando is a health care worker at a busy TB clinic. It
is the end of a very busy Friday afternoon. He is trying to wrap
things up and go home after his extremely stressful week. He is
going through the patient-related papers and forms he has been working
on that day. He is on his way to put the papers and forms in the
file cabinet when he is interrupted by a phone call from his babysitter.
His babysitter explains that she has to leave early that day. Thinking
it is an emergency, Rolando hastily hands over the files to his
co-worker Sam in the clinic area. He asks Sam to put the files on
his desk. Before getting a reply from Sam, he leaves. Sam was not
very happy because he was just leaving himself. He ends up leaving
the files on the table in the clinic, an area where other TB patients
may see the files.

What measures should Rolando have taken to protect
patient confidentiality?

Rolando should have ensured that patient records that contain
patient names and other identifying information are placed in
a closed locked file cabinet. In addition, no papers should
be exposed when workers are away from the work area, even for
brief periods of time. Health care workers have a duty to protect
patient records from unauthorized access. Information should
be kept in closed, locked file cabinets except when being processed
by authorized officials.

7.5 Another outreach worker, Janice, has been trying to contact
her patient Jerry for several days. She has visited his home several
times, and tried to call him on the telephone. One time when she
visits Jerry's house she sees Jerry's neighbor. The neighbor tells
Janice that Jerry just left. Janice introduces herself to Jerry's
neighbor and explains that she is from the TB clinic in the health
department and is looking for Jerry. She tells the neighbor that
the reason she is looking for Jerry is that he has TB and has missed
taking treatment for over 1 week. She also tells the neighbor that
if she sees Jerry to please tell him that she has stopped by to
see him. Finally, she leaves a message for Jerry on the door of
his apartment. She does not have any envelopes for her letter but
decides Jerry must really get her message and so she tapes it to
his front door.

Did Janice do anything that possibly threatens Jerry's
confidentiality? What measures should she have taken to protect
patient confidentiality?

Yes. Janice revealed private information about Jerry to Jerry's
neighbor without authorization. Janice must be discreet when
making patient visits. She should not have disclosed Jerry's
condition to Jerry's neighbor. Also, she should not have revealed
that she was from the TB clinic in the health department. Janice
could have gathered information on Jerry's whereabouts without
revealing sensitive information to Jerry's neighbor. Finally,
when Janice left the letter on Jerry's door, it should have
been left in a sealed envelope, marked "Confidential," and addressed
specifically to Jerry.